Background

Disability and slow return to sport and work after tendon rupture are major challenges. Platelet Rich Plasma (PRP) is an autologous supraphysiological concentration of platelets from whole blood that has demonstrated positive cellular and physiological effects on healing in laboratory conditions but evidence from adequately powered robust clinical trials is lacking. We aimed to determine the clinical efficacy of PRP for treatment of acute Achilles tendon rupture.

Aims

To determine whether platelet-rich plasma (PRP) injection improves outcomes two years after acute Achilles tendon rupture.

Aims

The rationale for exacting restoration of skeletal anatomy after unstable ankle fracture is to improve outcomes by reducing complications from malunion; however, current definitions of malunion lack confirmatory clinical evidence.

The Ankle Injury Management (AIM) trial was a pragmatic equivalence randomized controlled trial conducted at 24 hospitals in the United Kingdom that recruited 620 patients aged more than 60 years with an unstable ankle fracture. The trial compared the usual care pathway of early management with open reduction and internal fixation with initially attempting non-surgical management using close contact casting (CCC). CCC is a minimally padded cast applied by an orthopaedic surgeon after closed reduction in the operating theatre. The intervention groups had equivalent functional outcomes at six months and longer-term follow-up. However, potential barriers to using CCC as an initial form of treatment for these patients have been identified. In this report, the results of the AIM trial are summarized and the key issues are discussed in order to further the debate about the role of CCC. Evidence from the AIM trial supports surgeons considering conservative management by CCC as a treatment option for these patients. The longer-term follow-up emphasized that patients treated with CCC need careful monitoring in the weeks after its application to monitor maintenance of reduction.

Cite this article: Bone Joint J 2019;101-B:1472–1475.

Aims

Hip fractures are associated with high morbidity, mortality, and costs. One strategy for improving outcomes is to incentivize hospitals to provide better quality of care. We aimed to determine whether a pay-for-performance initiative affected hip fracture outcomes in England by using Scotland, which did not participate in the scheme, as a control.

Aims

The aim of this study was to explore the patients’ experience of recovery from open fracture of the lower limb in acute care.

Aims

We wished to assess the feasibility of a future randomised controlled trial of parathyroid hormone (PTH) supplements to aid healing of trochanteric fractures of the hip, by an open label prospective feasibility and pilot study with a nested qualitative sub study. This aimed to inform the design of a future powered study comparing the functional recovery after trochanteric hip fracture in patients undergoing standard care, versus those who undergo administration of subcutaneous injection of PTH for six weeks.

Multiple organ failure (MOF) is a major cause of trauma mortality and morbidity. The role of surgical procedures in precipitating MOF remains unclear.

Data on timing and duration of surgery was collated on 491 consecutive patients admitted to a Major Trauma Centre, who survived more than 48 hours and required Intensive Care Unit admission. MOF was defined according to the Denver Post Injury MOF Score, where MOF can occur only later than 48 hours after injury to exclude physiological derangements resulting from inadequate resuscitation.

Overall, 268 patients (54.6%) underwent surgery within 48 hours of injury, with 110 (22.4%) requiring surgery within 6 hours of injury. Total mean intra-operative time (p=0.067) nor the need for an operation within the first 6 (p=0.069) or 48 hours (p=0.124) were associated with MOF development. Multivariate predictive modelling of MOF showed timing and duration of surgery had no significant predictive power for MOF development (Odds Ratio 0.72, 95% CI 0.47–1.10).

Despite previous indication that early surgical intervention can precipitate MOF, current surgical strategy does not appear to impact MOF development.

We investigated whether, in the management of stable paediatric fractures of the forearm, flexible casts that can be removed at home are as clinically effective, cost-effective and acceptable to both patient and parent as management using a cast conventionally removed in hospital. A single-centre randomised controlled trial was performed on 317 children with a mean age of 9.3 years (2 to 16). No significant differences were seen in the change in Childhood Health Assessment Questionnaire index score (p = 0.10) or EuroQol 5-Dimensions domain scores between the two groups one week after removal of the cast or the absolute scores at six months. There was a significantly lower overall median treatment cost in the group whose casts were removed at home (£150.88 (sem 1.90) vs £251.62 (sem 2.68); p <  0.001). No difference was seen in satisfaction between the two groups (p = 0.48).

Cite this article: Bone Joint J 2013;95-B:1714–20.

Aim

Paediatric fractures are common but those occurring in non-ambulant children are associated with higher rates of Non Accidental Injury (NAI). There is little published on the mechanisms of injury associated with accidental fracture in young children. This study explores the aetiology of long bone fractures in non-ambulant children.

Purpose

Platelet-Rich Plasma (PRP), an autologous derivative of whole blood that contains a supraphysiological concentration of platelets and growth factors. Most published studies have investigated the effect of PRP-conditioned media on cell cultures. We are not aware of any study that has investigated whole PRP with its cellular components on human tissue cultures. This study aims to investigate the effect of PRP on cell migration from human Achilles tendon explants, and the subsequent cellular proliferative effects in culture.

Aims and methods

We present a review of our use of the Ilizarov apparatus in a non-acute NGO hospital in Cambodia specialising in limb reconstruction. Frames are applied without on table image intensification. A retrospective case-note analysis of Ilizarov apparatus use for all indications was conducted. 53 frames were applied between November 2005 and October 2011. Indications for application were chronic open fracture, osteomyelitis, fracture malunion, infective and non-infective non-union, bone lengthening, primary bone tumour resection, ankle fusion, congenital deformity or pseudarthrosis, chronic hip dislocation, or a combination of the above.

Purpose

Platelet Rich Plasma (PRP) has been shown to have positive effect in tendon regeneration in in-vitro and limited in-vivo animal studies. We aim to study PRP use in acute Achilles tendon rupture (ATR) regeneration in a purposely designed clinical trial.

Introduction

It has been suggested that the transition phases of implementing daylight saving time (DST) may impact on serious or fatal injuries sustained as the result of road traffic collision (RTC). The aim of this study is to explore the effects of transitions into and out of daylight saving time on the incidence of such injuries.

Purpose

Functional ultrasound Elastography (FUSE) of Tendo Achilles is an ultrasound technique utilising controlled, measurable movement of the foot to non-invasively evaluate TA elastic and load-deformation properties. The study purpose is to assess Achilles tendons, paratenon and bursa mechanical properties in healthy volunteers and establish an outcome tool for TA treatment.

Introduction

The use of platelet-rich concentrate (PRC) to enhance the healing response in tendon repair is currently an area of considerable interest. Activated platelets release a cocktail of growth factors and ECM regulating molecules. Previous work suggests that tenocytes are activated by contact with these clot-derived molecules. Our studies on tenocytes and PRC aim to establish the direct molecular and functional effects of PRC on tenocytes and to support the clinical research on Achilles tendon repair taking place within our group. We hypothesise that applying PRC to human tenocytes in culture will increase proliferation rate and survival by activating relevant signalling pathways.

Background

To determine the relative contributions of bilateral versus unilateral femoral shaft fracture plus injuries in other body regions to mortality after injury.

Introduction

Around the knee high-energy fractures/dislocation may present with vascular injuries. Ischaemia time i.e. the time interval from injury to reperfusion surgery is the only variable that the surgeon can influence. It has been traditionally taught that 6-8 hours is revascularisation acceptable. There are only limited case series that have documented the time-dependent lower limb salvage rate (LSR) or the lower limb amputation rate (LAR). We have conducted a meta-analysis to look at LSR and LAR to inform clinical standard setting and for medicolegal purposes.

We summarise findings from surveys of graduates from UK medical schools over 31 years. Serial surveys have been undertaken in 1974, 1977, 1980, 1983, 1993, 1996, 1999, 2000 and 2002. Questionnaires were sent to 33,151 doctors; 24,621 (74.3%) replied. Three years after qualification, 70.8% replied to a second survey; 5-years after qualification, seven cohorts were re-surveyed.

Trauma and orthopaedic surgery was the first choice career for 5.0% (men) and 1.0% (women) 1 year after qualification, and 5.2% (men) and 0.8% (women) at 5 years. Of those with T&O as first choice, 35% who chose it in year one, 56% in year three, and 84% in year five were working in it eventually. Experience as a student or junior, self-appraisal of skills, a particular teacher and enthusiasm for the specialty were the most important influences.

There has been an increase in the percentage of women choosing surgical careers. However, the much higher percentage of men who choose T&O surgery remains striking. The specialty needs to consider whether this matters. Women currently comprise about 60% of the medical school intake in the UK.

This study shows that doctors who ultimately pursued a surgical career made that choice by year 3 (equivalent to ST1) and between 84-92% had settled on the specialty by year 5 (ST3). Career progression for this historical cohort did not require an early commitment and a greater decisiveness may be anticipated in the more expectant system of Modernising Medical Careers.

It is unknown whether recent working time directives will influence career choice. This study defines T&O doctors to be highly motivated by work and not influenced by long working hours or competing domestic demands. This low priority places the specialty at the bottom of comparative tables. A change in work-life balance may directly impact future specialty recruitment.

If the lower re-rupture in operative treated patients was an effect of tendon-end apposition, then patients in whom that could be demonstrated in equinus by ultrasound could be equally well treated non-operatively without the attendant surgical risk.

All patients undergoing ultrasound for a suspected Achilles tendon repair between January 2000-2005 were included. Patients with a residual gap, 5mm or more in equinus; were treated by surgical repair. Those with a gap of less than 5mm were treated non-operatively. We excluded patients with no rupture, partial rupture and musculo-tendinuous junction (MTJ) tears. We recorded the following: clinical findings, ultrasound measurements of tendon gap in neutral and equinus, distance of rupture from distal insertion, the treatment and complications. All patients were followed up to a minimum of 6 months.

156 patients were treated for a clinical Achilles tendon rupture during the study period. We excluded 5 patients with no rupture on ultrasound, 15 with a MTJ tear, 7 with a muscle tear and 4 patients did not follow the protocol. 125 patients comprising 88 males and 37 females were entered into the study. 67 patients were treated operatively (37 open, 30 percutaneous) and 58 non-operatively. There was no significant difference between the 2 groups with respect to age, sex and injury mechanism. Two patients in the non-operative group had a re-rupture (3.4%) compared with 1 (1.5%) in the non-operative group. There were 2 incidences of superficial wound infection and 2 of temporary dorsal foot numbness in the operative. One patient in the non-operative group had a DVT. There was no significant difference for any of the complications between the two groups.

It may be possible to reduce the risk of re-rupture and surgery using dynamic ultrasound to determine which treatment the patient receives.

Background

Referral to centres with a pelvic service is standard practice for the management of displaced acetabular fractures.

Quality assurance for training in trauma and orthopaedics was provided by the JCHST through the SAC for Trauma and Orthopaedics. To date there have been written SAC standards; some are compulsory and others advisory and will generate requirements or recommendations to change if unmet on inspection. There has been a major change in the way postgraduate training is monitored and quality assured, with the formation of the PMETB, which now has the combined responsibility for all postgraduate training.

The aims and objectives of our study were to measure the effectiveness of the current quality assurance system for training in Trauma and Orthopaedics, and to determine the reduction in the number of unmet compulsory standards at the end of the visits process and how effectively these requirements were implemented. We also identified the deficiencies in each component of training and determined the current general profile of the quality of training in Trauma and Orthopaedics. The inspection visits, progress and revisit reports were collected from training regions that were visited after the standards were implemented.

In 109 units, in the 3 years studied, the inspection process reduced the overall unmet standards from a mean of 14.8% (10.3-19.2%) to 8.9% (6.5%-12.7%). The number of unmet requirement per unit fell from 4.6 to 2.8 (p<0.05). 27% of units did not improve. Overall 15% of standards were deficient, least in Scottish units and most in Irish units. Currently registrars do 1.4 trauma lists, 2.8 elective lists, 1.3 fracture clinics and 2.1 elective clinics per week. This is the first multi-regional study of a national accreditation process. Quality assurance requires standards setting and rectification. These findings are important for the imminent restructuring by the Postgraduate Medical Education Board.

Background: It has been suggested that the transition phases of implementing daylight saving time (DST) may impact on serious or fatal injuries sustained as the result of road traffic collision (RTC). The aim of this study is to explore the effects of transitions into and out of daylight saving time on the incidence of such injuries.

Methods: This is a comparative observational study of 11-year of data submitted prospectively to the Trauma Audit Research Network (TARN) between 1996 and 2006. Data for 4 weeks before and after time transition in spring and autumn of each year was collected. The time periods selected reflect those hours with maximum light level changes due to time alterations (2-hour around sunrise and 4-hour around sunset). Travellers outside those hours are unlikely to be affected by the changes.

Results: Out of 55,826 incidents in England and Wales, TARN returned 1296 incidents meeting the above time criteria, of which 282 involved a fatality. Overall, there were more crashes in autumn (845, 65.2%) comparing to spring period (451, 34.8%), with the majority occurring around sunset (1057, 81.5%). RTC related injuries at the onset of DST in spring showed a significant increase up to 14 days post time change (P=0.029), with the majority of the increase occurring at sunset. The highest increases occurred within the fatal incidents group (P=0.0019) and affected mainly the pedestrian subgroup (P=0.013). Changes in the incidence of injuries around the change back to Greenwich Mean Time (GMT) in autumn did not reach significance.

Conclusion: The use of DST over the period studied was associated with rise in RTC related injury figures up to two weeks following the spring time transition. These findings inform the continuing clock changes debate. The introduction of 2-hour time change may result in detrimental effects on RTC related injuries.

Impaired vascularity of the skin in elderly ankle fracture patients causes the skin and wound complications. This is part of a RCT comparing ORIF and close contact casting (CCC) for isolated unstable ankle fractures in patients > 60 years. Assessments over 6-months

trans-cutaneous O2 saturation (TcP02) of medial and lateral ankle skin

The uninjured limb was the control.

Eighty-nine patients eligible; 59 participated (76% female). 30 randomised to ORIF; 29 to CCC. Each had one death and one withdrawal. Vascular data available on 55. Two patients had delays in wound healing (> 25% for > 6-weeks). Two further developed wound infections. No skin breakdowns in CCC group. There was a reduced TcP02 on day-3 in the injured limb. The TcP02 rose at 6-weeks compared to day-3 (medial 58mmHg; lateral 53mmHg, p=0.002) in the injured leg. At 6-months the TcP02 measurements were not different to uninjured leg. A critical TcP02 (< 20mmHg) found in 4, correlated with skin problems (p=0.003). Two of these had the only major delays in wound healing and one of the two wound infections.

94% of participants had normal ABPI’s (> 1.0). There was no difference between patients with or without an impaired ABPI (< 0.7 mm Hg) and wound problems (p=0.20).

There was no difference in patent perforators between the injured and uninjured (p=0.39).

Occult vascular insufficiency is present but at low incidence. ABPI and Duplex-US are insensitive for predicting infection or delayed healing. The ankle fracture injury does not disrupt the local perforators. TcPO2 is sensitive and specific for predicting skin problems. Impairment of skin oxygenation is transient. Current TcPO2 technology however is impractical as a clinical tool.

This study aims to determine, by outcome analysis, the appropriateness of current criteria employed to select patients for total hip arthroplasty (THA) as the primary treatment for displaced intracapsular hip fracture (DICHF) and to inform prospective randomised controlled trials investigating the efficacy of THA as a primary treatment.

Contemporary THA eligibility criteria were derived from recent publications relating to pre-fracture residence, mobility and independence. Outcome data were analysed for 96 patients (19% of 506 consecutive patients with DICHF between 2003–2005) who fulfilled those criteria. The variables analysed included age, gender, co-existing injuries, co-morbidities, social circumstances, mobility, independence, delay to surgery, readmission, and death. Patients were followed for three years. The primary outcome was the combined achievement of home or warden-assisted accommodation at three months, no re-admission within 6 weeks and survival to 1 year. Secondary outcome was survival to three years.

At 3-months 86 patients (90%) had returned home, three (3.1%) required nursing or residential home placement, four (4.2%) were still resident in a community hospital, and three (3.1%) had died. Eight patients (8.3%) were re-admitted within 6-weeks. Mortality was 8.3% at 1-year and 25% at 3-years. Patients not achieving return to home were older (84.8 years vs. 79.7 years, p=0.19), were more likely to use a walking aid (OR 2.35) or required home support (OR 1.74) prior to fracture. The number of co-morbidities was not an association. Backward selection identified age as a significant variable in patients successfully discharged home (OR 1.12, CI 1.01 – 1.21).

If maintaining a high level of activity and independence is the expectation for hip fracture patients considered for THA then current selection criteria appear appropriate in identifying those 15% capable of returning home, remaining independent and surviving to one year.

Objectives: to determine whether initial contact with emergency services via a mobile phone (MP) in life threatening situations is associated with increased survival or reduced length of stay when compared to contact via a landline.

A retrospective cohort – data from all emergency dispatches from a UK county ambulance service was linked to the Patient Admission System at local hospitals. All emergency dispatches for immediately life-threatening events (designated as Code Red) between 01/01/1995 and 31/06/2006 were tracked to death or discharge.

Main Outcome Measures:

Mortality (at scene, at emergency department, and during hospitalisation), admissions (to the emergency department (ED), inpatients care, and the intensive care unit (ICU)) and mean lengths of stay were analysed by initial exposure (MP versus landline) using multi-variant analysis with logistic regression controlling for potential confounding variables.

354,199 ambulances were dispatched in the 11.5 years. Mobile phone use rose to 25% by study end. 66% of ambulances subsequently transferred patients to hospital. MP compared to landline reporting of emergencies resulted in significant reductions in the risk of death at scene for medical events (OR 0.74; 95% CI 0.65 to 0.85), but not for trauma (OR 1.04). ED medical deaths were higher (OR 1.33; 95% CI 1.33 to 1.72) as were in-patient (OR 1.19). There was no effect on ED or hospital trauma deaths (ORs 0.81, 0.84). The probability of being admitted to hospital and ICU was higher with MP call for trauma (ORs 1.22, 1.44). There was no difference in mortality between mobile or landline calls from either urban or rural areas.

There is little evidence to suggest a lower threshold to make an emergency call from a MP. The potential advantages of MP use of ease of access, supplying bystander/patient advice and shortening the ‘golden hour’ appear confined to non-trauma emergencies.

We evaluated the cost and consequences of proximal femoral fractures requiring further surgery because of complications. The data were collected prospectively in a standard manner from all patients with a proximal femoral fracture presenting to the trauma unit at the John Radcliffe Hospital over a five-year period. The total cost of treatment for each patient was calculated by separating it into its various components. The risk factors for the complications that arose, the location of their discharge and the mortality rates for these patients were compared to those of a matched control group. There were 2360 proximal femoral fractures in 2257 patients, of which 144 (6.1%) required further surgery. The mean cost of treatment in patients with complications was £18 709 (£2606.30 to £60.827.10), compared with £8610 (£918.54 to £45 601.30) for uncomplicated cases (p < 0.01), with a mean length of stay of 62.8 (44.5 to 79.3) and 32.7 (23.8 to 35.0) days, respectively. The probability of mortality after one month in these cases was significantly higher than in the control group, with a mean survival of 209 days, compared with 496 days for the controls. Patients with complications were statistically less likely to return to their own home (p < 0.01).

Greater awareness and understanding are required to minimise the complications of proximal femoral fractures and consequently their cost.

Spiral fractures are one of the most common fractures seen in non-accidental injury. In such cases, with radiographic evidence for the mechanism of injury, the physician is more capable of identifying any inconsistencies in the offered explanatory history.

The objectives of the study were to detail and differentiate the fracture patterns created by rotation forces in different directions and to determine the reliability of that recognition method applied to standard radiographs.

Twenty rabbit femurs were fractured using a torque transducer and imaged using standard anterior-posterior and lateral radiographs. The radiographic interpretation skills of paediatric, radiology, orthopaedic and emergency room doctors were assessed before and after being given the findings of this study.

The radiographic propagation of the spiral fractures was consistent and followed six simple principles. There was a statistically significant difference in the numbers of correctly diagnosed radiographs, before and after the explanation of our findings, by these doctors (chi-squared=14.06, df=1, p=0.002).

The direction of the torsional force producing spiral fractures can be determined from characteristic features on routine radiographs but does not seem to be intuitive. These derived six principles will be a useful aid to physicians who manage paediatric spiral fractures where non-accidental injury is being considered.

In 2006 the standard prosthesis for hip hemiarthroplasty in our unit was changed from the traditional Thompson prosthesis used for over 20 years to the monobloc Exeter Trauma Stem (ETS). The principle anticipated advantages were ease of stem implantation, improvement of orientation positioning and a consistency with modern proven femoral THR stem design.

All patients selected for hemiarthroplasty replacement for a displaced subcapital fracture of the hip were eligible for inclusion. Failed previous surgical cases were excluded.

The last 100 Thompson’s prostheses used before and the first 100 Exeter Trauma Stems undertaken after the changeover date were studied. Outcomes measured included surgical complications including infection, dislocation, fracture, necessity to ream etc. and technical adequacy of implant positioning based upon post-operative radiographs. Surgeon grade was recorded. There were no changes in surgical personnel.

206 consecutive patients were included in the study (age range 76–96); 67 men and 139 women. Data were collected prospectively as part of a comprehensive hip fracture audit.

Initial results show that the rate of surgical complications is similar in both prosthesis groups. Radiographs demonstrate the presence of a learning curve in the use of the new prosthesis. On six occasions after December 2006 the Thompson prosthesis was used – this was due to unavailability of ETS prosthesis or where a very large femoral head (56mm) was required.

The introduction of the ETS for hip hemiarthroplasty was successful. Initial conversion problems involved maintaining sufficient stock of the most commonly used size of prosthesis. Advantages were a low dislocation rate despite the greater potential for erroneous implant version and a reduction in the amount of femoral preparation required including reaming. Limitations of this study are the lack functional outcome and long term survivorship analysis.

Although mechanical stabilisation has been a hallmark of orthopaedic surgical management, orthobiologics are now playing an increasing role. Platelet-rich plasma (PRP) is a volume of plasma fraction of autologous blood having platelet concentrations above baseline. The platelet α granules are rich in growth factors that play an essential role in tissue healing, such as transforming growth factor-β, vascular endothelial growth factor, and platelet-derived growth factor. PRP is used in various surgical fields to enhance bone and soft-tissue healing by placing supraphysiological concentrations of autologous platelets at the site of tissue damage. The easily obtainable PRP and its possible beneficial outcome hold promise for new regenerative treatment approaches.

The aim of this literature review was to describe the bioactivities of PRP, to elucidate the different techniques for PRP preparation, to review animal and human studies, to evaluate the evidence regarding the use of PRP in trauma and orthopaedic surgery, to clarify risks, and to provide guidance for future research.

Introduction: Although a relationship between long-bone fractures and patient morbidity and mortality has been previously identified, the cause and effect of bilateral femoral fractures remain obscure.

Aim of Study: This study was designed to determine whether patients with bilateral femoral fractures with associated injuries die more frequently than patients with isolated bilateral femoral fractures, and the contribution of the associated injuries to patient mortality.

Materials and Methods: Retrospective analysis using the UK trauma Audit & Research Network (TARN) registry data from 1989 to 2005 on isolated bilateral femoral fractures ‘Group I’ (92) or with associated injuries ‘Group II’ (380). Univariate data analysis was performed to compare the groups’ ages, Injury Severity Scores, Glasgow Coma Scales, mortality, physiological parameters, the time to arrive to scene and the time to arrive to hospital. Logistic regression data analysis was performed to determine variables statistically associated with mortality.

Results: Patients in Group II had a significantly higher Injury Severity Score (23 vs 9), lower Glasgow Coma Scales value (12 vs 15), higher mortality rate (31.6 vs 9.8%) and lower mean systolic pressures (116 vs 135) than patients in Group I. Associated injuries included; head, thoracic, abdominal, spinal, and limb injuries. Regression analysis of variables on admission revealed a significant correlation between bilateral femoral fractures with associated injuries and.

Conclusion: From the results of this study, we conclude that patients sustaining bilateral femoral fractures with associated injuries are at a greater risk of than patients with isolated bilateral femoral fractures.

Background: The safest and most effective method of early spine clearance in unconscious patients is the subject of intense debate.

Hypothesis: Helical CT is a sufficiently sensitive investigation to render dynamic screening of the cervical spine redundant.

Protocol: Our protocol for cervical spinal clearance in the unconscious patient since April 1994 involves the use of plain radiographs, CT scan (helical CT since 1997) and dynamic screening (DS).

Method: Over a ten-year period, April 1994 to September 2004, 839 patients were admitted to intensive care under the orthopaedic surgeons. 35 patients were excluded because of incomplete records.

Results:

Demographics: The mechanism of injury was a road traffic accident in 80% and the mean ISS was 24.1. There were 95 patients (10.9%) with a cervical spine fracture, 96 (10.8%) with a fracture in either / both thoracic and lumbar regions.

Conclusion: DS is a safe procedure but has no real advantage over helical CT. Power’s ratio calculation is essential to reduce the chance of a missing an upper cervical injury. The cervical spine can be reliably cleared using helical CT alone.

Introduction: Previous reports have highlighted the impact of emergent crazes such as in-line skating and micro-scooters, with attention being drawn to potential accident prevention and emergent injury patterns.

A modern craze is the Harry Potter series of books. UK sales of the latest book, The Half-Blood Prince, are estimated to reach 4 million. Given the lack of horizontal velocity, height, wheels or sharp edges we were interested to investigate the impact the books had on children’s traumatic injuries.

Methods & Materials: A retrospective review was undertaken of Children aged 7 to 15 attending the Emergency Department of our Level 1 trauma unit over the summer months of a 3 year period.

The launch dates of the most recent two books (Order of the Phoenix and The Half-Blood prince) were identified and the admissions for these weekends were compared to surrounding summer weekends and those dates in previous years.

Data were obtained from MetOffice (www.metoffice.gov.uk) to establish weather conditions recorded for each of the identified weekends. This would enable us to adjust for this as a confounding variable if necessary.

Results: The mean attendance for children aged 7 to 15 years for this period was 65.1 (median 66, standard deviation 13.289, standard error 2.771). For the two intervention weekends the attendance rate was 36 and 37. This represents a significant decrease in emergency department attendances on those weekends (p < 0.05).

MetOffice data suggested no confounding effect of weather.

Discussion & Conclusion: Harry Potter books appear to protect children from traumatic injuries. The Royal Society for the Prevention of Accidents (rospa.org.uk) is dedicated to the identification and prevention of high risk childhood activities and produce guidelines on keeping children safe. To date no research has addressed the option of ‘distraction therapy’ to prevent injuries.

This is a retrospective case review of 237 patients with displaced fractures of the acetabulum presenting over a ten-year period, with a minimum follow-up of two years, who were studied to test the hypothesis that the time to surgery was predictive of radiological and functional outcome and varied with the pattern of fracture. Patients were divided into two groups based on the fracture pattern: elementary or associated. The time to surgery was analysed as both a continuous and a categorical variable. The primary outcome measures were the quality of reduction and functional outcome. Logistic regression analysis was used to test our hypothesis, while controlling for potential confounding variables.

For elementary fractures, an increase in the time to surgery of one day reduced the odds of an excellent/good functional result by 15% (p = 0.001) and of an anatomical reduction by 18% (p = 0.0001). For associated fractures, the odds of obtaining an excellent/good result were reduced by 19% (p = 0.0001) and an anatomical reduction by 18% (p = 0.0001) per day.

When time was measured as a categorical variable, an anatomical reduction was more likely if surgery was performed within 15 days (elementary) and five days (associated). An excellent/good functional outcome was more likely when surgery was performed within 15 days (elementary) and ten days (associated).

The time to surgery is a significant predictor of radiological and functional outcome for both elementary and associated displaced fractures of the acetabulum. The organisation of regional trauma services must be capable of satisfying these time-dependent requirements to achieve optimal patient outcomes.

Introduction: Proximal femoral fracture (PFF) is the leading cause of Trauma admission. Deep surgical wound infection occurs in approximately 3% of these patients. The purpose of this study was to assess the cost of deep infection to the patient, in terms of mortality and social consequences, and to the National Health Service, in terms of financial burden.

Methods: 61 consecutive patients (51 females, 10 males) treated for PFF, complicated with deep surgical wound infection over a seven-year period are presented. A control group consisting of 122 patients, without infection, were individually case matched (2:1) for factors that affect outcome after PFF (age, sex, ASA grade, fracture type, operation, and pre-fracture residence, social dependence, and mobility). Outcomes included length of admission (Trauma unit, rehabilitation bed, community hospital), number of operations, antibiotic administration and outpatient treatment, final destination, and mortality at one, three, and six months. A total cost of treatment was obtained from this data and supplied finance department figures.

Results: MRSA was responsible for 31 cases. Infected cases required an average of two wound debridements. 16 patients had a Girdlestones procedure of whom two were subsequently revised to total hip replacement. For all patients, the average Trauma unit admission was 58 days in the infected cases, with a further 40 days spent in rehabilitation or community beds, versus 16 days and 27 days respectively in the controls (p < 0.001). 34% of infected cases died before discharge versus 15% of controls (p = 0.004). For the patients surviving to discharge, the mean total hospital stay was 124 days for the infected cases versus 45 days in the controls (p < 0.001). A higher proportion of the survivors in the control group returned to their original residence compared to the infected survivors (p = 0.002). The mortality rates in the infected group were 15% at 1 month, 31% at 3 months, and 38% at six months, versus 9%, 20%, and 25% respectively in the control group (p = 0.36, 0.12, 0.12). The median cost of treatment per infected case was 23960 versus 7390 per control case.

Conclusions: Deep surgical wound infection after proximal femoral fracture is a devastating complication for both the patient and the NHS. It is associated with a higher in-patient mortality, and fewer survivors return to their pre-fracture residence. Hospital stay is greatly increased and survivors spend 4 months on average in hospital. Additional costs are huge and are incurred at all levels. The extra financial cost of treating a single infected case would fund the treatment of two non-infected cases. These costs should be considered when allocating funds and beds to Trauma services, in addition to ensuring measures known to minimise infection rates are in place.

Incomplete intertrochanteric fractures do not extend across to the medial femoral cortex and are stable, without rotational deformity or shortening of the lower limb. The aim of our study was to establish whether they can be successfully managed conservatively. A total of 68 patients over a five-year period presented with a suspected fracture of the femoral neck and underwent an MRI scan for further assessment. From these, we retrospectively reviewed eight patients with normal plain radiographs but with an incomplete, intertrochanteric fracture on MRI scan. Five were managed conservatively and three operatively.

The mean length of hospital stay was 16 days for the conservatively-treated group and 15 days for those who underwent surgery; this was not statistically significant (p > 0.5) and all patients were mobilised on discharge. Although five patients were readmitted at a mean of 3.2 years after discharge, none had progressed to a complete fracture. We believe that patients with incomplete intertrochanteric fractures should be considered for conservative treatment.

Aims: To evaluate the functional outcome following internal fixation of distal humerus intra-articular fractures (AO type C) with a minimum follow up of two years. Methods: Design: Retrospective evaluation and clinical review. Setting: Regional trauma centre Patients and Participants: Twenty six consecutive patients with fractures of the distal humerus were treated over a thirty one month period (June 1993 to December 1995). The mean age was 55years (range,18–82). Clinical review of twenty patients at a mean follow up of more than two years (range 19–48 months). Six patients were lost to follow up. Results: Clinical evaluation of twenty patients was carried out. Fourteen patients (70 percent) had an excellent or good outcome, five patients (25 percent) a fair outcome and one patient (5 percent) had a poor result. Three patients (15 percent) underwent a second procedure for symptomatic metalwork. The mean arc of flexion-extension was 112 degrees (range, 85 to 122 degrees). Fifteen patients (75 percent) were able to return to their pre injury level of occupation and activity. Seventeen patients (85 percent) were satisfied with the final outcome. Conclusion: nternal fixation of intra-articular distal humerus fractures is an effective procedure with an excellent/good functional outcome in most patient age groups. Patients have a high level of satisfaction and return to previous level of activity.

Aims: to evaluate the outcome following internal þxation of olecranon fractures using the techniques of tension band wiring and plating with a minimum follow up of two years. Methods:Design: retrospective evaluation and clinical review. Setting: regional trauma centre. Patients and participants: 48 consecutive patients with fractures of the olecranon were treated over a twenty month period (may 1993 to december 1994). 25 fractures were þxed using a tension band wiring technique and 23 underwent plating; the selection of method was based on agreed radiological fracture pattern criteria. Main outcome measurements: radiographic evaluation of the quality of reduction. Clinical outcome (broberg and morrey functional rating index). Results: clinical evaluation of 39 patients was carried out. In the tension band wiring group 17 (85 percent) patients had an excellent or good outcome and 11 (55 percent) patients underwent a second procedure for symptomatic metalwork. In the plating group 16 (84 percent) patients had an excellent or good outcome and 2 (11 percent) patients underwent a second procedure for symptomatic metalwork. The latter group had more complex and associated fractures and included the only poor result. Conclusion: internal þxation of fractures of the olecranon results in good functional outcome. Fixation with a plate is effective and produces good outcome even though selected for the more complex olecranon fractures. Patients who have tension band wiring more often require a second procedure for removal of symptomatic metalwork.

The purpose of the study was to ascertain whether there were benefits from surgical treatment of acetabular fractures within 3 days of injury, as opposed to within a 2–3 week time period as stated in the current literature.

This is a matched-pair, retrospective study, using prospectively entered data from 2 trauma units’ databases, of patients with acetabular fractures treated operatively between 1991 and 1996. Patients were matched for age, acetabular fracture pattern and associated injuries. One group of patients had surgery within 3 days of injury (median time to surgery 1. 5 days), the other group had surgery at 4 or more days post-injury (median 8 days, range 4–19 days). There were 128 patients, 64 per group.

The proportion of patients with complications was higher in the later surgery group (relative risk 2. 1, CI 0. 24–0. 87). Median lengths of stay were significantly shorter in the early surgery group, 11 days compared to 22 days (p< 0. 001 Mann-Whitney-U test). The rate of HO in the early surgery group was 2% compared with 14% in the later surgery group. The rate of good or excellent results was 81% in patients with earlier surgery, and 72% in the later surgery group, in those with median follow-up time of 24 months.

Surgery for acetabular fractures can and should be undertaken as soon as possible. In the setting of our Trauma Units, this seems to confer lower risks of early and late complications, shorter inpatient stay and may improve long-term outcome.

In the light of EEC proposals on the avoidance of damage to hearing caused by noise, a study was undertaken to determine the risk posed by powered orthopaedic instruments. The noise levels from a number of air-powered and electric tools were measured and analysed and found to exceed the recommended levels. The predicted daily personal noise exposure was calculated and the potential for hearing damage confirmed. Twenty-seven senior orthopaedic staff were then assessed by audiometry; evidence of noise-induced hearing loss was found in half the subjects. The increasing use of powered instruments in elective orthopaedics and fracture fixation may present a significant cumulative risk to the hearing of orthopaedic surgeons and theatre personnel. The use of ear defenders should be promoted, and manufacturers should be encouraged to develop instruments with lower noise emission levels.

A prospective study of 120 consecutive total hip replacements showed that deep suction drains produced maximal drainage volumes in the first 24 hours. Their continued presence resulted in minimal further drainage, did not reduce the likelihood of haematoma formation and led in some cases to the spread of skin organisms into the wound.